Healthcare Provider Details

I. General information

NPI: 1568967461
Provider Name (Legal Business Name): MIRIAM KIRORI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRIAM KIRORI

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 03/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD APT 2A
ELKHART IN
46514-2483
US

IV. Provider business mailing address

600 EAST BLVD
ELKHART IN
46514-2483
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-3334
  • Fax:
Mailing address:
  • Phone: 574-523-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: